The Joint Commission
Quality Check
Quality Report

Summary of Accreditation Quality Information
Tennova Healthcare-Physicians Regional Medical Center
DBA: Physicians Regional Medical Center
Org ID: 7852
900 E. Oak Hill Avenue
Knoxville, TN  37917
(865)865-8000
www.tennovahealthcare.com


Accreditation
Programs
Accreditation
Decision
Effective
Date
Last Full Survey Date Last On-Site Survey Date
Behavioral Health Care
Accredited 7/15/2014 7/14/2014   7/14/2014  
Home Care
Accredited 7/19/2014 7/18/2014   7/18/2014  
Hospital
Accreditation with Follow-up Survey 7/19/2014 7/18/2014   8/29/2014  
The following standard(s) were found to be out of compliance:
  • A time-out is performed before the procedure.
  • Leaders use hospitalwide planning to establish structures and processes that focus on safety and quality.
  • Maintain and communicate accurate patient medication information.
  • Medical staff bylaws address self-governance and accountability to the governing body.
  • Staff participate in ongoing education and training.
  • The decision to grant or deny a privilege(s), and/or to renew an existing privilege(s), is an objective, evidence-based process.
  • The governing body is ultimately accountable for the safety and quality of care, treatment, and services.
  • The hospital addresses patient decisions about care, treatment, and services received at the end of life.
  • The hospital collects data to monitor its performance.
  • The hospital determines how staff function within the organization.
  • The hospital effectively manages its programs, services, sites, or departments.
  • The hospital establishes and maintains a safe, functional environment. Note: The environment is constructed, arranged, and maintained to foster patient safety, provide facilities for diagnosis and treatment, and provide for special services appropriate to the needs of the community.
  • The hospital implements its infection prevention and control plan.
  • The hospital maintains the integrity of the means of egress.
  • The hospital manages risks associated with its utility systems.
  • The hospital provides and maintains systems for extinguishing fires.
  • The hospital provides care, treatment, and services as ordered or prescribed, and in accordance with law and regulation.
  • The hospital provides the patient with care before initiating operative or other high-risk procedures, including those that require the administration of moderate or deep sedation or anesthesia.
  • The hospital reduces the risk of infections associated with medical equipment, devices, and supplies.
  • The hospital safely manages high-alert and hazardous medications.
  • The organized medical staff oversees the quality of patient care, treatment, and services provided by practitioners privileged through the medical staff process.
  • The person from the hospital whose name appears on the Clinical Laboratory Improvement Amendments of 1988 (CLIA '88) certificate identifies the staff responsible for performing and supervising waived testing. Note 1: Responsible staff may be employees of the hospital, contracted staff, or employees of a contracted service. Note 2: Responsible staff may be identified within job descriptions or by listing job titles or individual names.




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  Symbol Key
This organization achieved the best possible results
This organization’s performance is above the target range/value.
This organization’s performance is similar to the target range/value.
This organization’s performance is below the target range/value.
This measure is not applicable for this organization.
Not displayed
  Footnote Key
1. The measure or measure set was not reported.
2. The measure set does not have an overall result.
3. The number is not enough for comparison purposes.
4. The measure meets the Privacy Disclosure Threshold rule.
5. The organization scored above 90% but was below most other organizations.
6. The measure results are not statistically valid.
7. The measure results are based on a sample of patients.
8. The number of months with measure data is below the reporting requirement.
9. The measure results are temporarily suppressed pending resubmission of updated data.
10. Test Measure: a measure being evaluated for reliability of the individual data elements or awaiting National Quality Forum Endorsement.
11. There were no eligible patients that met the denominator criteria.
National Patient Safety Goals and National Quality Improvement Goals
    Compared to other Joint Commission Accredited Organizations
    Nationwide Statewide
Behavioral Health Care
2014 National Patient Safety Goals See Detail
This organization’s performance is similar to the target range/value.
This Goal is not applicable for this organization.
*
Home Care
2014 National Patient Safety Goals See Detail
This organization’s performance is similar to the target range/value.
This Goal is not applicable for this organization.
*
Hospital
2014 National Patient Safety Goals See Detail
This organization’s performance is similar to the target range/value.
This Goal is not applicable for this organization.
*
National Quality Improvement Goals:    
Reporting Period:
Jan  2013 -
Dec  2013
Heart Attack Care See Detail
This organization’s performance is above the target range/value.
This organization’s performance is above the target range/value.
Heart Failure Care See Detail
This organization’s performance is similar to the target range/value.
This organization’s performance is similar to the target range/value.
Pneumonia Care See Detail
This organization’s performance is above the target range/value.
This organization’s performance is above the target range/value.
 
National Quality Forum The Joint Commission only reports measures endorsed by the National Quality Forum.
 
* State results are not calculated for the National Patient Safety Goals.

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Sites and Services
* Primary Location

An organization may provide services not listed here. For more information refer to the Quality Report User Guide .

Locations of Care Available Services
North Knoxville Medical Center
7565 Dannaher Drive
Powell, TN  37849
    Services:
    • CT Scanner (Imaging/Diagnostic Services)
    • Dialysis Unit (Inpatient)
    • Ear/Nose/Throat Surgery (Surgical Services)
    • EEG/EKG/EMG Lab (Imaging/Diagnostic Services)
    • Gastroenterology (Surgical Services)
    • GI or Endoscopy Lab (Imaging/Diagnostic Services)
    • Gynecological Surgery (Surgical Services)
    • Inpatient Unit (Inpatient)
    • Magnetic Resonance Imaging (Imaging/Diagnostic Services)
    • Medical /Surgical Unit (Inpatient)
    • Medical ICU (Intensive Care Unit)
    • Nuclear Medicine (Imaging/Diagnostic Services)
    • Ophthalmology (Surgical Services)
    • Orthopedic Surgery (Surgical Services)
    • Plastic Surgery (Surgical Services)
    • Positron Emission Tomography (PET) (Imaging/Diagnostic Services)
    • Post Anesthesia Care Unit (PACU) (Inpatient)
    • Radiation Oncology (Imaging/Diagnostic Services)
    • Sleep Laboratory (Sleep Laboratory)
    • Surgical ICU (Intensive Care Unit)
    • Teleradiology (Imaging/Diagnostic Services)
    • Thoracic Surgery (Surgical Services)
    • Ultrasound (Imaging/Diagnostic Services)
    • Urology (Surgical Services)
    Physicians Regional Medical Center  *
    900 East Oak Hill Avenue
    Knoxville, TN  37917
      Services:
      • Behavioral Health (Day Programs - Adult)
        (24-hour Acute Care/Crisis Stabilization - Adult)
        (Partial - Adult)
      • Brachytherapy (Imaging/Diagnostic Services)
      • Cardiac Catheterization Lab (Surgical Services)
      • Cardiac Surgery (Surgical Services)
      • Cardiothoracic Surgery (Surgical Services)
      • Cardiovascular Unit (Inpatient)
      • Chemical Dependency (Day Programs - Adult)
        (24-hour Acute Care/Crisis Stabilization - Adult)
        (Partial - Adult)
      • Coronary Care Unit (Inpatient)
      • CT Scanner (Imaging/Diagnostic Services)
      • Dialysis Unit (Inpatient)
      • Ear/Nose/Throat Surgery (Surgical Services)
      • EEG/EKG/EMG Lab (Imaging/Diagnostic Services)
      • Family Support (Non 24 Hour Care)
      • Gastroenterology (Surgical Services)
      • General Laboratory Tests
      • GI or Endoscopy Lab (Imaging/Diagnostic Services)
      • Gynecological Surgery (Surgical Services)
      • Gynecology (Inpatient)
      • Hematology/Oncology Unit (Inpatient)
      • Inpatient Unit (Inpatient)
      • Interventional Radiology (Imaging/Diagnostic Services)
      • Labor & Delivery (Inpatient)
      • Magnetic Resonance Imaging (Imaging/Diagnostic Services)
      • Medical /Surgical Unit (Inpatient)
      • Medical ICU (Intensive Care Unit)
      • Normal Newborn Nursery (Inpatient)
      • Nuclear Medicine (Imaging/Diagnostic Services)
      • Ophthalmology (Surgical Services)
      • Orthopedic Surgery (Surgical Services)
      • Orthopedic/Spine Unit (Inpatient)
      • Outpatient Clinics (Outpatient)
      • Peer Support (Non 24 Hour Care)
      • Plastic Surgery (Surgical Services)
      • Positron Emission Tomography (PET) (Imaging/Diagnostic Services)
      • Post Anesthesia Care Unit (PACU) (Inpatient)
      • Radiation Oncology (Imaging/Diagnostic Services)
      • Surgical ICU (Intensive Care Unit)
      • Surgical Unit (Inpatient)
      • Teleradiology (Imaging/Diagnostic Services)
      • Thoracic Surgery (Surgical Services)
      • Toxicology
      • Ultrasound (Imaging/Diagnostic Services)
      • Urology (Surgical Services)
      • Vascular Surgery (Surgical Services)
      St. Mary's Surgery Center
      1515 St. Mary's St.
      Knoxville, TN  37917
      Other Clinics/Practices located at this site:
      • Pain Center
      Services:
      • Ambulatory Surgery Center (Outpatient)
      • Anesthesia (Outpatient)
      • Perform Invasive Procedure (Outpatient)
      Tennova Ambulatory Care Center South
      7323 Chapman Hwy, Ste 190
      Knoxville, TN  37920
        Services:
        • Outpatient Clinics (Outpatient)
        Tennova Cardiac Rehab Services
        PRMC Professional Bldg Suite 810 900 E.Oak Hill Ave
        Knoxville, TN  37917
          Services:
          • Outpatient Clinics (Outpatient)
          Tennova Comprehensive Pain Treatment Center
          7551 Dannaher Drive
          Powell, TN  37849
            Services:
            • Anesthesia (Outpatient)
            • Outpatient Clinics (Outpatient)
            • Perform Invasive Procedure (Outpatient)
            Tennova Comprehensive Pain Treatment Center Turkey Creek
            10820 Parkside Drive, Suite 208
            Knoxville, TN  37934
              Services:
              • Anesthesia (Outpatient)
              • Outpatient Clinics (Outpatient)
              • Perform Invasive Procedure (Outpatient)
              Tennova Home Care Equipment (DME)
              314 Merchants Drive, Suite D
              Knoxville, TN  37912
                Services:
                • Canes and Crutches
                • Commodes
                • Continuous Positive Airway Pressure
                • Durable Medical Equipment
                • Hospital Beds - Electric
                • Invasive Mechanical Ventilation
                • Nebulizers
                • Oxygen
                • Patient Lifts and Accessories
                • Prosthetics (Home Medical Equipment)
                • Respiratory Equipment
                • Seat Lift Mechanisms
                • Suction Pump
                • Support Surfaces - For Beds
                • Tracheostomy Supplies
                • Ventilators Accessories/Supplies
                • Walkers, Canes and Crutches
                • Wheelchair Seating / Cushions
                • Wheelchairs - Manual Non-Custom
                • Wheelchairs-Standard Manual Accessories
                Tennova Home Care Equipment (DME)
                DBA:  Tennova DME
                120 Hospital Drive
                Jefferson City, TN  37760
                  Services:
                  • Continuous Positive Airway Pressure
                  • Respiratory Equipment
                  Tennova Home Care Equipment DME
                  DBA:  Tennova DME
                  7323 Chapman Highway Suite 16
                  Knoxville, TN  37920
                    Services:
                    • Continuous Positive Airway Pressure
                    • Respiratory Equipment
                    Tennova Home Care Equipment DME
                    DBA:  Tennova DME
                    10820 Parkside Drive
                    Knoxville, TN  37934
                      Services:
                      • Continuous Positive Airway Pressure
                      • Respiratory Equipment
                      Tennova Home Care Equipment DME
                      DBA:  Tennova DME
                      7540 Dannaher Way
                      Powell, TN  37849
                        Services:
                        • Continuous Positive Airway Pressure
                        • Respiratory Equipment
                        Tennova Home Health
                        7203 Chapman Highway
                        Knoxville, TN  37920
                          Services:
                          • Home Health Aides
                          • Home Health, Non-Hospice Services
                          • Medical Social Services
                          • Occupational Therapy
                          • Physical Therapy
                          • Skilled Nursing Services
                          • Speech Language Pathology
                          Tennova Physical Therapy and Sports Medicine, North
                          7540 Dannaher Drive, Suite 200
                          Powell, TN  37849
                            Services:
                            • Outpatient Clinics (Outpatient)
                            Tennova Residential Hospice
                            7447 Andersonville Pike
                            Knoxville, TN  37938
                              Services:
                              • Hospice Care
                              Tennova Sleep Center North
                              7540 Dannaher Drive, Suite 300
                              Powell, TN  37849
                                Services:
                                • Outpatient Clinics (Outpatient)
                                Tennova Sleep Center South
                                7323 Chapman Highway
                                Knoxville, TN  37920
                                  Services:
                                  • Outpatient Clinics (Outpatient)
                                  Tennova Sleep Center West
                                  10820 Parkside Dr., 4th Floor
                                  Knoxville, TN  37934
                                    Services:
                                    • Outpatient Clinics (Outpatient)
                                    Tennova Surgery Center West
                                    10820 Parkside Drive
                                    Knoxville, TN  37934
                                      Services:
                                      • Ambulatory Surgery Center (Outpatient)
                                      • Anesthesia (Outpatient)
                                      • Perform Invasive Procedure (Outpatient)
                                      Turkey Creek Medical Center
                                      10820 Parkside Drive
                                      Knoxville, TN  37934
                                        Services:
                                        • Cardiac Catheterization Lab (Surgical Services)
                                        • Cardiac Surgery (Surgical Services)
                                        • Cardiothoracic Surgery (Surgical Services)
                                        • Cardiovascular Unit (Inpatient)
                                        • CT Scanner (Imaging/Diagnostic Services)
                                        • Dialysis Unit (Inpatient)
                                        • Ear/Nose/Throat Surgery (Surgical Services)
                                        • EEG/EKG/EMG Lab (Imaging/Diagnostic Services)
                                        • Gastroenterology (Surgical Services)
                                        • GI or Endoscopy Lab (Imaging/Diagnostic Services)
                                        • Gynecological Surgery (Surgical Services)
                                        • Gynecology (Inpatient)
                                        • Inpatient Unit (Inpatient)
                                        • Interventional Radiology (Imaging/Diagnostic Services)
                                        • Labor & Delivery (Inpatient)
                                        • Magnetic Resonance Imaging (Imaging/Diagnostic Services)
                                        • Medical /Surgical Unit (Inpatient)
                                        • Medical ICU (Intensive Care Unit)
                                        • Neurosurgery (Surgical Services)
                                        • Normal Newborn Nursery (Inpatient)
                                        • Nuclear Medicine (Imaging/Diagnostic Services)
                                        • Ophthalmology (Surgical Services)
                                        • Orthopedic Surgery (Surgical Services)
                                        • Plastic Surgery (Surgical Services)
                                        • Post Anesthesia Care Unit (PACU) (Inpatient)
                                        • Radiation Oncology (Imaging/Diagnostic Services)
                                        • Sleep Laboratory (Sleep Laboratory)
                                        • Surgical ICU (Intensive Care Unit)
                                        • Teleradiology (Imaging/Diagnostic Services)
                                        • Thoracic Surgery (Surgical Services)
                                        • Ultrasound (Imaging/Diagnostic Services)
                                        • Urology (Surgical Services)
                                        • Vascular Surgery (Surgical Services)

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